Combat Fatigue

Barry Roma, a postal worker and a disabled Vietnam veteran, tells people not to be afraid of him. He is joking, sort of. He knows how veterans -- and postal workers -- are seen by many people, and luckily he has a sense of humor. By night, he works as a mail handler in Chicago and by day, as national coordinator for Vietnam Veterans Against the War. He helps to put out a biannual publication, The Veteran, and works closely with members of Iraq Veterans Against the War. His achievements are hard-earned.

More than 40 years ago, as an officer in Vietnam, he witnessed wartime atrocities that could easily be classified as war crimes. The events occurred decades ago, but they continue to haunt and nearly overwhelm him with remorse. He watched American soldiers demolish villages, burn houses, and shoot civilians. After seeing friends blown up by landmines, he enlisted the help of local farmers, asking them to walk ahead of U.S. troops to look for hidden bombs. No one was hurt during these particular incidents, he says, but he cannot shake the memory of what he did. In May 1968, he left Vietnam to bring home the body of his nephew, a teenager who, he says, "was like my brother."

Back in San Bernadino, California, Roma enrolled at a local college and tried to get on with things, but he discovered that he could not sleep. "I had a tremendous amount of adrenaline," he says. "A couple hours of sleep a night was just perfect." Roma, who is now 60, says he began to drink heavily. (He remembers lots of "sangria with dry ice.") And, though he did not know it at the time, he showed symptoms of post-traumatic stress disorder (PTSD), including anxiety and nightmares.

The situation for vets like Roma was particularly difficult, says Michael Blecker, 58, executive director of a San Francisco-based veterans' organization called Swords to Plowshares, because of the lack of understanding about their problems. Blecker got his start in the field of veterans' rights as a law school student in 1976, helping people like Roma file claims for government medical benefits. Many soldiers were coming home from Vietnam and suffering from the same post-traumatic stress Iraq veterans now face. Yet there was no such thing as PTSD, at least not officially. Instead, it was known as post-Vietnam syndrome, and often it was not even recognized. "You couldn't compensate somebody who was having problems with ?whatever the hell it was,'" Blecker says.

Roma eventually received disability benefits from the U.S. Department of Veterans Affairs. But many others who have returned from a war zone (whether in Vietnam, Iraq, or Afghanistan) with shattered nerves have not fared as well. Approximately 18 veterans kill themselves every day, according to an e-mail from a Veterans Affairs official that was revealed in April after two veterans' groups, Veterans for Common Sense and Veterans United for Truth, filed a lawsuit in federal court in San Francisco. More recently, the Army reported that its personnel committed suicide at the highest rate on record in 2007, and the trend is continuing in 2008. Given the severity and magnitude of the problem -- Veterans Affairs saw 400,000 veterans for PTSD last year -- the Pentagon and administration officials are eager to find a way to address the issue. There have been various approaches, including efforts to cut back on compensation claims. Recently, an advocacy group called revealed an email written by an official from Olin E. Teague Veterans' Center in Temple, Texas, suggesting mental-health specialists should hold back on diagnosing PTSD. Instead, the official suggested, they should "consider a diagnosis of Adjustment Disorder."

In general, however, officials are searching for a comprehensive solution. If things go as hoped, veterans like Roma will not have these problems in the future -- not because they will be treated effectively once they return from war, but because they will never suffer from the disorder in the first place.

With the support of funding from the National Institutes of Health, researchers are searching for ways to quiet the demons that soldiers face after wartime through a controversial program known as "therapeutic forgetting" or, more commonly, as "memory dampening." The treatment, at least in theory, will allow veterans to avoid symptoms of post-traumatic stress, and perhaps the disorder entirely, by using pharmaceutical means to shape their memory. It includes the use of the beta-blocker drug propranolol, which is now commonly taken for high blood pressure, and aims to help tamp down the jagged, painful thoughts that follow traumatic experiences. While still in an experimental stage, memory dampening -- at least in the view of some veterans' advocates -- is a metaphor for the way administration, Defense Department, and Veterans Affairs officials, not to mention many Americans, are approaching the problem of war trauma during the Iraq experience. Combat, as wretched as it is, is part of a soldier's life and is embedded in our national psyche, too. The best thing to do, they argue, is to wipe out memories of it?in other words, simply to forget these things happened and to move on.

Whether or not that is a good thing depends on whom you ask. Researchers see all sorts of benefits in the treatment, including the possibility of alleviating suffering of men and women who have served in war and are now seeking peace of mind, or at least a good night's sleep. Ethicists are less sure. They say the ability to remember experiences, even painful ones, is part of what allows us to feel empathy and compassion and makes us fully human. Veterans like Roma are clear on their views. "I am really against it," he says. "Problems have to be dealt with."

The number of american soldiers who have fought in Iraq and Afghanistan in recent years is daunting: Approximately 1.6 million men and women have been deployed to the Middle East since 2002. More than 4,000 have been killed in the Iraq War, and tens of thousands have been maimed, wounded, or are currently suffering the psychological scars. Given the scale of damage, it makes sense to search for something that reduces the incidence of one of the most common ailments -- PTSD. The rate of PTSD among these veterans is extraordinarily high and may be unprecedented.

Iraq and Afghanistan veterans are known as the "new kids," at least among people like Thomas Berger, chairman of Vietnam Veterans of America's National PTSD and Substance Abuse Committee. He says he has been surprised at the number of Iraq War veterans who have been diagnosed with post-traumatic stress: 16 percent among those who have served one tour of duty; 20 percent among those who have served two tours; and 30 percent among those who have been to Iraq three times. That is roughly the percentage of Vietnam veterans who say they have suffered from post-traumatic stress?in studies done years after the conflict.

The number of Iraq War veterans who suffer from PTSD is likely to increase with time. As Berger points out, "We have a large number of troops who are serving their fourth deployment." Soldiers who serve more than three tours of duty are at an especially high risk. Meanwhile, the new demographics of the Army mean more people are affected by the illness today than in decades past. During the Vietnam era, the soldiers were young and mainly single. Today, an increasing number of soldiers are married and have children, and their difficulties in adjusting to "Fort Living Room," as it is known, are spilling into family life. Spouses and children of soldiers are being diagnosed with post-traumatic stress, too, suffering from the effects of their loved ones' multiple and prolonged deployments. This has increased the number of individuals with post-traumatic stress nationwide and has put a heavy burden on the health-care system.

Officials working at Veterans Affairs are trying to address the problem. Over the past two and a half years, the department has hired more than 3,800 new employees to address mental-health issues. In addition, funding for mental-health services has increased from $2 billion in 2001 to this year's "projected amount" of over $3.5 billion, says Jim Benson, a department spokesperson. The additional resources have gone, in part, to the creation of 23 new Vet Centers, community-based outreach centers throughout the nation that are staffed by psychologists, nurses, and social workers, bringing up the total to 232.

But too often, they are failing. Veterans are falling through the cracks, waiting months or even years for the treatment, counseling, and medication they need. Many of these men and women are -- like Roma did in years past -- turning to alcohol or, in many cases, drugs. "If you can't sleep at night," says Steven Southwick, a Yale professor and Veterans Affairs psychiatrist, "you will find a way."

As the number of suicides among veterans suggests, the consequences of these postwar mental disorders can be fatal. In fact, according to Mark S. Kaplan, co-author of an article on the subject in the July 2007 issue of the Journal of Epidemiology and Community Health, suicide is a leading cause of death among veterans, ahead of even natural causes and homicide.

Critics of the Bush administration say the problems many veterans face today have been caused in part by the government's approach to war -- mainly, by going into Baghdad with little thought about the repercussions of the invasion. The problem, say veterans' advocates, is that Veterans Affairs was never prepared for the aftermath of war, nor for the cost of caring for thousands of veterans. Columbia University's Joseph Stiglitz and Harvard University's Linda Bilmes, co-authors of a new book, The Three Trillion Dollar War, have found that providing disability benefits, medical care, and Social Security disability compensation to Iraq and Afghanistan veterans over the course of their lives will cost between $350 billion and $700 billion.

It should have come as no surprise that officials were unprepared for the aftermath of the Iraq War in this country, especially given the lack of postwar planning in Iraq. Nevertheless, the scale of the damage -- physical, emotional, and economic -- is huge.


There is nothing new about post--traumatic stress, and the contours of the illness are well known. It is an anxiety disorder brought on by exposure to a horrifying event, involving vivid, sometimes debilitating memories and is often accompanied by hyper-vigilance and sleeplessness. Characteristics of it are described in the Iliad and the Odyssey, and it was officially recognized as a medical disorder in the United States in 1980.

When individuals are exposed to extraordinary stress, they release a high level of hormones. This is known as a "fight-or-flight reaction" and is, of course, a good thing because it helps people protect themselves from danger. Being stressed out is a natural response to combat, and there seems to be no reason to fight it. But for researchers who study this phenomenon, and for those who examine the problems that follow soldiers home from war, one question comes up frequently: Why is PTSD different? Most people recover from stress, even in its most extreme versions, several weeks or months after the incident. However, if too many hormones are released during or after the stressful episode, the body gets out of whack. Unfortunately, this happens to some individuals who are exposed to stress during wartime.

Among these individuals, the hormone levels have increased so dramatically that they do not recede in a timely fashion and can even alter memory capacity. Men and women with PTSD may have heightened memories of the trauma. The experience can be easily reactivated for them, set off by the pop of a helium balloon or the crack of a rifle. Stress hormones are released each time they relive the traumatic event, and the memories become even more intense with time. People who have served in combat may, decades later, continue to show elevated levels of adrenaline, explains Yale's Steven Southwick. In addition to being hyperaware, these men and women may also have problems with memory and find it difficult to absorb new information.

Researchers have determined that some individuals may be more likely to experience post-traumatic stress because of their genetic makeup and their personal background. The hippocampus is a region of the brain, for example, that is critical for short-term memory. Scientists have discovered it is smaller in people with post-traumatic stress.

Environment also plays a role. Individuals who have strong social networks and solid educational and family backgrounds seem less likely to suffer from post-traumatic stress. Rockefeller University's Bruce S. McEwen, one of the nation's leading neuroscientists, says people who have been abused or neglected as children may have more difficulties when they face traumatic situations as adults. "Early life experiences create vulnerability," he explains. Not surprisingly, some experts have suggested that military officials screen prospective recruits before admitting them to the armed forces. But there are problems with this kind of vetting system -- namely, it might be difficult to find enough soldiers. "A lot of the recruits are from disadvantaged backgrounds, and it may rule out the majority of people who enlist and end up going into combat," says McEwen. "We would have to rely on a draft, and there'd be an outcry."

A recent review of literature conducted by the Institute of Medicine, which is part of the National Academy of Sciences, shows that the only proven, effective treatment for post-traumatic stress is exposure therapy, which allows patients to relive the original experience of trauma in a therapeutic setting. The findings do not mean antidepressants and other forms of therapy do not work -- just that they do not have significant scientific evidence to support them. In other words, despite the fact that post-traumatic stress has been around for centuries, we still do not really know how to help people who suffer from it. Yet, the problem is so urgent and widespread that there has been pressure to ramp up the efforts to address it. Partly for these reasons, researchers have been trying to come up with a method that would rid the armed forces of PTSD entirely.

The leading contender is memory dampening. This approach, still in the early stages of scientific development, uses the beta-blocker drug propranolol to help suppress the production of hormones in individuals exposed to extreme stress so they are not produced at dangerously high levels. The drug is given shortly after a traumatic experience. One scientist, Larry Cahill, a neurobiologist at the University of California, Irvine, has conducted an experiment in which he shows people a series of slides with a wrenching back story and then administers propranolol. Two weeks later, according to a description of the study in a 1994 Nature article, "Beta-Adrenergic Activation and Memory for Emotional Events," the subjects who have received a dosage of propranolol seem to recall the images with a lower level of emotional intensity than those who did not. The drug has apparently tamped down emotional reactions. Preliminary findings seem to indicate that if an individual receives the drug around the time of a highly traumatic event, it will muffle the memory of the event, making it less sharp and emotionally charged.

"We ask people with PTSD, 'Would you [sacrifice] some of your so-called normal memory if it were to help you?'" says Joseph LeDoux, a New York University professor of neuroscience who studies emotional memory. "Across the board, they said 'Yes.'"

Yet some ethicists and scientists wonder if the cure is worse than the disease. In October 2003, the President's Council on Bioethics issued a report titled, "Beyond Therapy: Biotechnology and the Pursuit of Happiness," which looked at ethical dimensions of scientific research. One area is memory dampening. At the time, the Iraq War was in an early phase. The number of soldiers who had experienced PTSD was only a fraction of what it is now, and the discussion about pharmaceutical-based therapies for post-traumatic stress seemed theoretical. "Soon, doctors may have just the 'sweet oblivious antidote' that Macbeth so desired: drugs (such as beta-adrenergic blockers) that numb the emotional sting typically associated with our intensely bad memories," according to the report.

Yet even then, one of the report's co-authors, Rebecca Dresser, a professor of law and ethics at Washington University, says she and others were concerned about the implications of memory dampening. "What would our lives be like if people who had any kind of bad experience -- whether it's war or a bad childhood -- could just take a pill, and you remember it, but it just doesn't bother you as much?" she asks. "We talked about how many good things come out of bad experiences, at least on a social level. Some people who are in battle then become anti-war, and they certainly contribute a lot to society. And what would our society be like if going into war and killing people was no big deal? Imagine if going to war never made anyone feel bad about it."


For all sorts of reasons, memory dampening may not be the best solution to the problem of post-traumatic stress. But PTSD is not going away anytime soon. In fact, studies show the disorder often emerges long after the event. Experts say that means soldiers who have returned from Iraq and seem to be doing okay may in fact be headed for trouble. The vulnerable ones tend to show symptoms in three to five years, just as their families are feeling worn down from their care and they are left to their own devices. Unfortunately, there is not much of a safety net for these individuals.

Many believe that efforts to develop a radical treatment such as memory dampening, for all its scientific promise and therapeutic potential, are a move in the wrong direction. It may seem to be an effective way to care for soldiers who are experiencing pain and suffering. In fact, the treatment may allow society as a whole, and government officials in particular, to avoid taking responsibility for the Iraq War and future conflicts by making them seem less risky or consequential.

Regardless of the side effects, memory dampening does not promise to be a panacea. One of the most debilitating aspects of war trauma, say researchers, is the guilt that comes with it. These feelings may be rational, such as when an individual really did cause the death of another person. They may be irrational, such as when an individual survives and friends do not. "Medication -- that's not going to quiet down guilt," says Yale's Steven Southwick. "Guilt is so debilitating -- I can't tell you."

Few people understand this better than Roma. "Some of my worst dreams -- the deep-down dirty ones -- I can't even remember them," he says. "I'm in a psychological hole that's so deep and dark I don't even remember them when I wake up. I'm absolutely destroyed -- absolutely sweating. I'm really afraid of what's hiding down there."

Still, he believes these memories are important. "One of the things I'm proud of is that I feel guilty for the bad things I did," he says. "I feel guilty not just about my friends dying but also about what I did to Vietnamese people." He believes his feelings, however painful, have a positive side. He is now helping other veterans deal with their ghosts, and he gives talks to high school and college students about war. This work, he says, comes from remembering the pain and dealing with it -- not from trying to forget it.